Provider Demographics
NPI:1639182769
Name:FEDOR, ELANA (MD)
Entity type:Individual
Prefix:
First Name:ELANA
Middle Name:
Last Name:FEDOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 MEDICAL PARK RD
Practice Address - Street 2:STE 140A
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:704-663-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-00055207R00000X
ORMD27613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006211Medicaid
G29121Medicare UPIN
OR006211Medicaid
279826Medicare ID - Type Unspecified
OR279826Medicare PIN